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Neoadjuvant Chemotherapy in Breast Cancer

The administration of neoadjuvant chemotherapy (NAC): Offers several advantages in locally advanced breast cancer: It allows for downstaging the disease: Which can potentially allow for less extensive surgery in the breast and axilla It also provides information regarding the responsiveness of the cancer to systemic therapy while the tumor remains in vivo: Which can guide the course of…

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Management of Early Breast Cancer

National Comprehensive Cancer Network (NCCN) guidelines: Recommend surgical management: For local control for women with early stage invasive breast cancer Several studies have shown an equivalence in overall and / or breast cancer-specific survival rates: For breast conservation with radiation compared to mastectomy among early stage breast cancer patients For patients with ER positive…

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Pathologic Nipple Discharge

Pathologic nipple discharge: Is characteristically spontaneous, unilateral, or bloody Physiologic discharge: Is non-spontaneous, bilateral, and milk The most common causes for pathologic nipple discharge: Are benign: Intraductal papillomas Duct ectasia The presence of abnormal clinical findings on imaging or physical exam: Is associated with increased risk of malignancy: 38% vs.…

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Margins of Resection for Invasive Carcinoma of the Breast

The Society of Surgical Oncology / American Society for Radiation Oncology (SSO / ASTRO) 2014 Consensus Guidelines: Regarding margins of resection for invasive carcinoma of the breast: Recommend the use of “no ink on tumor” as the standard Patients with invasive cancer: Even with associated ductal carcinoma in situ (DCIS), are treated according to these guidelines In a meta-analysis of 33…

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Radiation Fractionation

Three important areas form the foundation for the evolving use of altered fractionation: Tissue response Duration of treatment Fraction size and number Acutely responding tissues: Are rather active in ongoing cellular proliferation Most tumors (except perhaps prostate cancer, breast cancers, and melanoma) and some normal tissues such as skin, mucous membranes, and gastrointestinal…

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Contralateral Prophylactic Mastectomy (CPM) American Society of Breast Surgeon Guidelines

Current consensus guidelines from the American Society of Breast Surgeons: Do not recommend CPM for women with sporadic breast cancers A Cochrane review of 8 studies evaluating patients who underwent CPM: Concluded that while CPM reduces risk of contralateral breast cancer: It is not associated with improved survival Reasons for not recommending CPM include: A low estimated risk of cancer…

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Nerves that Could Potentially be Injured During Breast and Axillary Surgery

Intercostobrachial nerve: This nerve is a cutaneous branch of the intercostal nerves: Most commonly the second intercostal nerve: Which gives off a lateral cutaneous nerve: Which continues as the intercostobrachial nerve The intercostal nerves arise from: The anterior rami of the thoracic spinal nerves The intercostobrachial nerve pierces the serratus anterior: Crosses the axilla to the…

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Hypofractionation Radiation Therapy

Hypofractionation: Larger fraction size (600 to 800 cGy) compared with conventional fractionation (180 to 200 cGy) Fractions delivered several days apart Lower total dosage (2100 to 3200 cGy) thanconventional fractionation (7000 cGy) Shortened overall treatment durationcompared with conventional fractionation Hypofractionation: Is the administration of high-dose-per-fraction (HDPF)…

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Radiation Therapy in Head and Neck Cancer

A randomized study by the radiation therapy oncology group (RTOG) 90–03: Evaluated the use of low-LET radiation alonewith four fractionation schemes for the treatment of squamous cell carcinoma of the head and neck Patients included in this trial underwent radiation therapy as a single modality, without the use of chemotherapy The sites included the oral cavity, oropharynx, hypopharynx, and…

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Axillary Web Syndrome

Axillary web syndrome: Appears to be a common complication following axillary surgery It consists of the appearance of a visible web of axillary skin overlying palpable cords of tissue: That are made taut and painful by shoulder abduction These cords can result in painful abduction of the shoulder and reduced range of motion It typically results from axillary lymphadenectomies for treatment…

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Pregnancy-Associated Breast Cancer

Pregnancy-associated breast cancer: Is fortunately a rare entity: In which breast cancer is diagnosed during the pregnancy or the first year after delivery The surgical care of these patients is the same as non-pregnant patients: Sentinel node biopsy: Can safely be performed during pregnancy: Therefore, axillary dissection is not warranted However, only radioactive dye should be…

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Omitting Axillary Staging In Women Older Than 70 Years of Age with Early Stage ER+ Breast Cancer

The standard of care with respect to surgical management of early stage breast cancer with a clinically negative axilla: Is to undergo axillary staging with sentinel lymph node mapping and biopsy (SLNM / SLNB) In patients who are clinically node negative undergoing lumpectomy with SLNB: A completion axillary lymph node dissection (ALND) is not required if one or two lymph nodes are…

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Staging of the Axilla Following Neoadjuvant Chemotherapy

As reported by Veronesi in 1999: 737 patients were randomized to either undergo Halsted mastectomy or extended mastectomy with IM node dissection After 30 years of follow-up: There was no difference in overall survival or disease-specific survival: For the patients eligible with T1, T2, T3, N0, and N1 disease who underwent IM node dissection vs. no IM dissection A 2019 retrospective review…

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Regionally Recurrent Breast Cancer - Management

Isolated recurrent axillary disease: Is an uncommon presentation of recurrence: The incidence remains rare at 1% to 2% It is important to stage patients with locoregional recurrences: As approximately one-third: Will present with synchronous distant metastasis If the staging workup is negative: A complete axillary dissection should be performed if possible If surgical resection is not…

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Phyllodes of the Breast

Phyllodes of the breast: Is a rare lesion Phyllodes are classified into three groups: Benign Borderline Malignant Borderline and malignant phyllodes: Have a higher incidence of local recurrence: Therefore, historically management was a mastectomy without nodal assessment Recently, more patients are undergoing lumpectomy for this lesion Researchers believe that local recurrence rates are…

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Tubular Carcinoma of the Breast

Tubular carcinoma: Is a distinct histopathologic subtype of breast cancer representing 1% to 2% of breast cancers diagnosed It is a distinct entity from low-grade ductal carcinoma The literature continues to suggest that it has an excellent prognosis: With a very low likelihood of distant metastasis and excellent disease-free survival In select patients, adjuvant therapies may be…

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21-Gene Recurrence Score Assay Defining Characteristics

Estrogen receptor positive (ER+) tumors: Can be very sensitive to endocrine therapy: Which may allow some patients to safely avoid chemotherapy However, the presence of ER receptors on immunohistochemistry: Does not necessarily mean that the tumor’s growth is being driven by ER-related pathways Additionally, other molecular features may influence the tumor cells’ sensitivity to hormonal…